Greater Cincinnati AOSA Chapter
Music and Movement Education

Greater Cincinnati AOSA Assistance Fund page 5

Lissa Ray 7835 Jolain Dr. Cincinnati OH 45242 LRay123@aol.com

Please contact Lissa above for the exact forms needed.
Use the page below for gathering the information you need to fill out the forms.

GREATER CINCINNATI AOSA ASSISTANCE FUND APPLICATION FINANCIAL STATEMENT ( Confidential )

 

NAME:

SOCIAL SECURITY #:

PLACE OF EMPLOYMENT:

FULL/PART TIME ?
( Give percent please)

ADDRESS

CITY:

STATE:

 

I. Anticipated Finances of the Assistance Fund Project :

A. Expenses:

Tuition	$
Materials	$
Travel	$
Lodging	$
Other (please give details)	$
Other	$
	TOTAL	$

B. Have funds been requested from your school district? Yes No

Amount granted…………………. $_____________

C. Portion of cost from other sources ( list below )................................ $

____________________________

D. Portion of cost you will assume:.......…………..................…………. $

E. Portion of cost requested from The Greater Cincinnati AOSA Assistance Fund. $__________

 

II. Your annual income :

	Last Year	This Year
A. Wages	$	$
B. Dividends	$	$
C. Interest	$	$
D. Other than A, B, C	$	$
E. Non taxable income	$	$

III. Spouse's income :

	Last Year	This Year
Spouse's income	$	$
IV. TOTAL	$	$

V. Federal Income tax you paid :

	Last Year	This Year
tax you paid	$	$

Vl. Federal Income tax of spouse :

	Last Year	This Year
	$	$

VII. Number of dependents :

Vlll. A Short statement of any special financial circumstances may be detailed on the back. Please include copies of the two most recent income tax returns you have filed

 

These facts are correct to the best of my knowledge.

Signature

 

Date